ISRNM PROCEEDINGS

To Eat or Not to Eat—International ExperiencesWith Eating During Hemodialysis TreatmentBrandon Kistler, MS, RD,* Deborah Benner, MA, RD, CSR,† Mary Burgess, MS, RD,‡

Maria Stasios, RDN, CSR, LDN,† Kamyar Kalantar-Zadeh, MD, MPH, PhD,§

and Kenneth R. Wilund, PhD*

Providing food or nutrition supplements during hemodialysis (HD) may be associated with improved nutritional status and reduced mor-

tality; however, despite these potential benefits, eating practices vary across countries, regions, and clinics. Understanding present

clinic practices and clinician experiences with eating during HD may help outline best practices in this controversial area. Therefore,

the objective of this study was to examine clinical practices and experiences related to eating during HD treatment. We surveyed clini-

cians about their clinic practices during the 2014 International Society of Renal Nutrition and Metabolism Conference. We received 73

responses from six continents. Respondents were primarily dietitians (71%)working at units housed in a hospital (63%). Sixty-one clinics

(85%) allowed patients to eat during treatment, with 47 of these patients (65%) actively encouraging eating. Fifty-three clinics (73%)

provided food during HD. None of the nine clinics fromNorth America, however, provided food during treatment. Themajority (47 clinics;

64%) provided supplements during treatment. Clinics in the hospital setting were more likely to provide food during treatment, whereas

outpatient clinics were less likely to provide nutrition supplements (P# 0.05 for both). We also asked clinicians about their experience

with six commonly cited reasons to restrict eating during treatment using a four-point scale. Clinicians responded they observed the

following conditions ‘‘rarely’’ or ‘‘never’’: choking (98%), reduced Kt/V (98%), infection control issues (96%), spills or pests (83%),

gastrointestinal issues (71%), and hypotension (62%). Our results indicate that while eating is common during treatment in some areas,

disparities may exist in global practices, and most of the proposed negative sequelae of eating during HD are not frequently observed in

clinical practice. Whether these disparities in practice can explain global differences in albumin warrants further research to help inform

decisions regarding eating during HD.

� 2014 by the National Kidney Foundation, Inc. All rights reserved.

Introduction

MAINTENANCE HEMODIALYSIS (HD) is ahighly catabolic condition. Poor nutritional status

is common in HD patients1 and is associated with reducedquality of life,2 increased hospitalizations,3 and increasedmortality.4 Providing patients with supplemental nutritionduring a single HD treatment increases skeletal muscleprotein synthesis, reduces catabolism, and improves net

*Department of Kinesiology and Community Health, University of Illinois at

Urbana-Champaign, Urbana, Illinois.†Clinical Enterprise, DaVita Healthcare Partners, Denver, Colorado.‡DaVita Clinical Research, DaVita Healthcare Partners, Denver, Colorado.§Harold Simmons Center, University of California at Irvine, Irvine,

California.

Support: B.K. is currently funded by an American Heart Association Predoc-

toral Fellowship. D.B. is currently employed by DaVita Healthcare Partners,

Denver, Colorado. M.B. is currently employed by DaVita Healthcare Partners,

Denver, Colorado. M.S. is currently employed by DaVita Healthcare Partners,

Denver, Colorado. K.K.-Z. is funded by National Institutes of Health grant

R21-DK078012 and philanthropic grants from Mr. Harold Simmons and

Mr. Louis Chang for this manuscript. K.R.W. is currently funded by the Na-

tional Institutes of Health grant R01-DK084016.

Address correspondence to Kenneth R. Wilund, PhD, Department of

Kinesiology and Community Health, University of Illinois, 906 S Goodwin

Ave, Urbana, IL 61801. E-mail: kwilund@illinois.edu� 2014 by the National Kidney Foundation, Inc. All rights reserved.

1051-2276/$36.00

http://dx.doi.org/10.1053/j.jrn.2014.08.003

Journal of Renal Nutrition, Vol 24, No 6 (November), 2014: pp 349-352

protein balance.5-7 Long-term provision of nutrition dur-ing HD treatment has been shown to increase nutritionalindicators such as albumin,8 lean mass,9 and subjectiveglobal assessment10 as well as quality of life.11 These im-provements in nutritional status may contribute to therecent observation that intradialytic oral nutrition supple-mentation programs are associated with significant reduc-tions in mortality.12,13

Despite these benefits, many clinics do not allow patientsto eat during HD treatment. Many reasons have been pro-posed to restrict patients from eating during HD, includinghemodynamic instability, choking risk, and reductions indialysis efficiency, among others14-16; however, theseconcerns are primarily anecdotal as there is little evidencein the published literature supporting them. The lack ofresearch on this topic may contribute to varying clinicalpractices.17 Furthermore, differences in clinic practices oneating during treatment have been suggested to contributeto the global disparities in albumin and other nutrition in-dicators.14,18 Describing international clinic practices is animportant step to better understand worldwide differencesin nutritional outcomes and determine best practices.Therefore, we set out to perform a survey to describeinternational practices on eating during treatment and toprovide insight into clinical experiences with eatingduring treatment.

349

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MethodsWe developed an 11-item survey about clinic practices

and clinician experiences related to eating duringHD treat-ment. This survey was developed based on a combinationof clinical experience and review of the literature.14-16

Demographic data for each participant were alsocollected. The survey was distributed to attendees duringthe 2014 International Society of Renal Nutrition andMetabolism Conference in Wurzburg, Germany19; all at-tendees were encouraged to respond. Collected surveyswere analyzed and entered into SPSS version 22 (IBM,Chicago, IL). Partial responses were included in the overallanalysis. Data are reported as the number of respondentsand the percent of categorical responses. A chi-square test(c2) was used to determine practice differences betweenclinic settings. Significance was set using an alpha of 0.05.However, no additional statistical comparisons were per-formed because of the limited number of responses. Finally,qualitative data were analyzed, clustered, and summarized.

ResultsWe received 73 responses from six continents (Africa [3,

4.1%], Asia [7, 9.6%], Australia [5, 6.8%], Europe [39,53.4%], North America [9, 12.3%], and South America[10, 13.7%]). Clinicians who responded to the surveywere dietitians (71.2%), nephrologists (26.0%), or clinicalresearchers (2.7%) who worked in units housed within ahospital (63.0%), outpatient clinic (45.2%), and/or an aca-demic setting (16.4%).

Clinic practices for eating duringHD treatment are sum-marized in Figure 1. Fifty-three clinics (72.6%) served foodother than supplements during HD. Forty-nine of the 53clinics who served food during treatment (92.5%) providedfood at no cost to the patient. However, none of the nineclinics from North America provided food during treat-ment. Clinics that were in a hospital setting were morelikely to provide food to patients during treatment thanthose that were not associated with a hospital (c2 5 3.84,P5.05). Qualitative analysis of clinician responses showed

Figure 1. International practices for patient eating patternsduring hemodialysis treatment.

that clinics providing food were generally providing fullmeals that tended to be high in carbohydrates. In addition,tea or coffee was often included as a beverage.Forty-seven clinicians responded that their clinics

(64.4%) provided supplements during treatment. Forty-three of the 47 clinics (91.5%) provided these supplementsat no cost to the patient. Outpatient clinics were less likelyto provide nutritional supplements during treatmentcompared with clinics that were not described as outpatient(c2 5 4.35; P , .04). Clinics tended to provide patientswith liquid as opposed to solid supplements. These supple-ments were most often commercially available mixedmacronutrient supplements.We also asked clinicians about their experiences with

eating during treatment. When asked whether four specificfactors influenced their decision to allow patients to eat, cli-nicians responded that they allowed patients to eat to provideadditional energy (88.7%), teaching opportunities (46.8%),better control of blood glucose (32.3%), and difficulty en-forcing a no eating policy (16.1%). Additionally, clinicianopen-ended responses included patient quality of life,providing protein, barriers to intake outside of the clinic(i.e., lack of cooking skills, transport time, socioeconomiclimitations, and so forth), clinic culture, and nutrient timing.Finally, we asked clinicians about six commonly cited reasonsto restrict feeding during HD. Clinician responses are sum-marized in Table 1. In general, clinicians did not frequentlyexperience these proposed consequences of eating duringtreatment. In addition to these commonly cited reasons, cli-nicians also indicated that staff workload, difficulty over-coming clinic culture, cost, and patients’ forgetting bindersas reasons to restrict eating during HD treatment.

DiscussionWe conducted a survey examining the practices and

experiences of clinicians related to eating during HD treat-ment at the International Society of Renal Nutritionand Metabolism Conference in Wurzburg, Germany.Our primary findings from this survey include thefollowing: (1) eating during dialysis is commonly allowedand frequently encouraged by clinics throughout most ofthe world; (2) many clinics provide food and supplementsto patients at no cost; (3) providing additional energyappears to be the primary reason that clinics allow orencourage patients to eat during treatment; and (4) manyof the proposed negative sequelae of eating during HDare not commonly observed in clinical practice. To ourknowledge, this is the first published study to describe in-ternational practices related to eating during treatment.Understanding the variability in clinic guidelines is an

important step to outlining best practices. We observedthat most clinics around the world allow, encourage, andin many cases, provide food at no cost to patients. However,none of the nine clinics from North America provided pa-tients with food. This supports previous reports indicating

Table 1. Clinician Experiences With Six Commonly Cited Reasons to Restrict Eating During Hemodialysis Treatment

Reason Never Rarely Occasionally Frequently

Postprandial hypotension (n 5 53) 18 (34.0) 15 (28.3) 18 (34.0) 2 (3.8)

Gastrointestinal symptoms (n 5 52) 14 (26.9) 23 (44.2) 15 (28.8) 0 (0.0)Reduced treatment efficiency (n 5 45) 42 (93.3) 2 (4.4) 1 (2.2) 0 (0.0)

Spills or pests (n 5 46) 31 (67.4) 7 (15.2) 5 (10.9) 3 (6.5)

Choking (n 5 46) 39 (84.8) 6 (13.0) 1 (2.2) 0 (0.0)

Infection control issues (n 5 46) 42 (91.3) 2 (4.3) 2 (4.3) 0 (0.0)

INTERNATIONAL EATING SURVEY 351

that practices related to eating during treatment in NorthAmerica, particularly the United States, appear to bemore restrictive.14 Although the present study is underpow-ered to make statistical comparisons between continents orcountries, this observation deserves further examination.Although speculative, this difference in clinical practicemay contribute to the observation that patients’ albuminlevels tend to be lower, and mortality rates higher, in theUnited States compared with the rest of the world.18

Another interesting observation was that the food beingprovided to patients was high in carbohydrates. This isimportant given our finding that approximately 37% of cli-nicians have observed hypotension at least ‘‘sometimes.’’Carbohydrates have been shown to lead to a dispropor-tionate postprandial drop in blood pressure comparedwith the other macronutrients20 although this effect hasnot been demonstrated in patients undergoingHD. In addi-tion, protein appears to be more effective at preventingHD-associated catabolism and inflammation5,6 and maylead to fewer hemodynamic complications. Furtherresearch may be warranted to determine the optimal foodchoices during HD treatment.We also asked clinicians about their experiences with pa-

tients eating during HD treatment. These clinical experi-ences contribute important evidence to the debate withinthe nephrology community about the best practices relatedto eating during treatment.14 Providing additional energywas the primary reason that clinics allowed patients to eatduring treatment. When asked about six commonly citedarguments for restricting eating during HD treatment, cli-nicians reported that the majority of these concernsoccurred ‘‘rarely’’ or ‘‘never.’’ The most frequently reportedconsequence of eating during treatment was intradialytichypotension. This is consistent with previous observationsthat eating during treatment causes a transient reduction inblood pressure but is generally well accepted in stable pa-tients (Kistler et al., manuscript in preparation). Describingthe frequency and individual circumstances with whichthese symptoms occur will help clinicians make informeddecisions regarding practices in this controversial area.A primary weakness of this study was that the data were

obtained from a convenience sample of clinicians attendinga renal nutrition conference. These practitioners are likelyto have greater interest in nutrition andmay havemore pro-gressive practices in their clinic related to eating during HDtreatment. In addition, this survey was written in English,

which may have limited the participation of nonnative En-glish speaking participants. We also did not receive anadequate number of responses to statistically compare con-tinents. Despite this limitation, the group as a whole hasprovided valuable insight into clinical experiences witheating during treatment. Additionally, this research hasraised important questions about differences in practicearound the world and how these may contribute to globaldisparities in nutritional status and outcomes.In summary, our results indicate that eating is common

during treatment in many countries around the world, dis-parities may exist in global practices, and most of the pro-posed negative sequelae of eating during HD are notcommonly observed in clinical practice. These datadescribe current nutrition practices, provide a potentialcontributor to global differences in albumin, and highlightthe need for more research to inform decisions regardingeating during HD. Specifically, future research should beconducted to further characterize and evaluate interna-tional differences in eating practices, to examine the prev-alence and severity of proposed consequences associatedwith eating during treatment, and to find ways to minimizepatient risk.

Practical ApplicationsThis study suggests that many of the proposed negative

consequences associated with eating during treatment arenot commonly observed by practitioners in the clinicalsetting. This observation should provide insight into cur-rent practices and highlight the need for future researchin this controversial area of practice.

AcknowledgmentThe authors would like to thank the International Society of Renal

Nutrition andMetabolism for allowing us to distribute our survey at their

conference.

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